Response to the COVID-19 Outbreak in Urban Settings in China

The COVID-19 outbreak in China was devastating, and spread throughout the country before being contained. Stringent physical distancing recommendations and shelter-in-place were first introduced in the hardest-hit provinces, and by March, these recommendations were uniform throughout the country. In the presence of an evolving and deadly pandemic, we sought to investigate the impact of this pandemic on individual well-being and prevention practices among Chinese urban residents. From March 2–11, 2020,4,607 individuals were recruited from 11 provinces with varying numbers of COVID-19 casers using the social networking app WeChat to complete a brief, anonymous, online survey. The analytical sample was restricted to 2,551 urban residents. Standardized scales measured generalized anxiety disorder (GAD), the primary outcome. Multiple logistic regression was conducted to identify correlates of GAD alongside assessment of community practices in response to the COVID-19 pandemic. We found that during the COVID-19 pandemic, recommended public health practices significantly (p<0.001) increased, including wearing facial mask, practicing physical distancing, handwashing, decreased public spitting, and going outside in urban communities. Overall, 40.3% of participants met screening criteria for GAD and 49.3%, 62.6%, and 55.4% reported that their work, social life, and family life were interrupted by anxious feelings, respectively. Independent correlates of having anxiety symptoms included being a healthcare provider (aOR=1.58, p<0.01), living in regions with a higher density of COVID-19 cases (aOR=2.13, p<0.01), having completed college (aOR=1.38, p=0.03), meeting screening criteria for depression (aOR=6.03,p<0.01) and poorer perceived health status (aOR=1.54,p<0.01). COVID-19 had a profound impact on the health of urban dwellers throughout China. Not only did they markedly increase their self- and community-protective behaviors, but they also experienced high levels of anxiety associated with a heightened vulnerability like depression, having poor perceived health, and the potential of increased exposure to COVID-19 such as living closer to the epicenter of the pandemic.


Introduction
The novel coronavirus disease 2019 (COVID-19) pandemic rst rapidly spread throughout China, and by August 19 th , 2020, it had manifested in 188 countries with 22,244,179 con rmed cases and 783,525 deaths worldwide. 1 In the absence of effective vaccines or treatments, public health authorities have relied upon sheltering in place (self-quarantine at home), physical distancing in public settings, hand washing and wearing facial masks to prevent further spread. 2,3 Without fully understanding its transmission, risk of progression, and widespread death from COVID-19, panic and even hysteria were common. 4 The World Health Organization made public the COVID-19 outbreak in January 2020, 5 and observed that the outbreaks were more severe in urban settings with a higher density of people. 6 Consequently, Chinese residents increasingly complied with recommended containment measures that are necessary under this time of crisis, but those measures could disrupt their work and social and family life. Also, during the pandemic, many urban dwellers remained relatively segregated within their neighborhoods, and this negatively impacted their psychological well-being. 7,8 Anxiety symptoms among urban dwellers dealing with a volatile COVID-19 pandemic, however, has not been broadly examined since it does not affect everyone equally. Over the past 18 years, various settings have reacted to new infectious diseases epidemics like SARS, MERS, and Ebola and, though none of these developed pandemic proportions, understanding factors that may undermine the health of the community are important for future public health disaster planning efforts. We, therefore, conducted a nationwide online survey of people in China to identify those factors associated with anxiety from COVID-19 and focused only on urban dwellers here, since they experienced COVID-19 differently than their nonurban counterparts.

Study design and participants
We conducted baseline, online survey with 4,607 participants living in China; two additional waves are underway. Participants inclusion criteria included: 1) ≥18 years old; 2) living in mainland China; 3) able to read Chinese; and 4) had access to WeChat (the largest social networking app in China). All recruited participants were asked to complete a baseline survey over ten days from March 2-11, 2020. A total of 4,607 individuals from 11 provinces, with the varied impact of the COVID-19 pandemic, completed the online survey. The analytical sample was restricted to 2,551 urban residents who completed the enrollment survey. In this paper, the time point of COVID-19 outbreak refers to January 23 rd , 2020, when Wuhan city was placed in quarantine. The study protocol was approved by the Institutional Review Board of Yale University and received ethical approval from Wuhan University.
To address the impact of the COVID-19 pandemic, the survey was developed, and pilot tested using methods that have been described elsewhere. 11 In brief, standardized scales were used, and responses to COVID-19 were created. After drafting candidate questions, ten experts in the eld took the survey and provided feedback to re ne the survey. The revised survey was then designed on Questionnaire Star (https://www.wjx.cn/), a professional platform for online surveys, 12 and a web link, and a QR code was generated. We then pilot-tested the survey with 32 individuals who accessed the survey from a weblink or QR code and sought feedback. Using feedback, we nalized the electronic survey and applied the webbased sampling method to recruit participants after identifying the seed in each province.
The selected 11 seed participants completed the survey and then distributed a yer that contained recruitment information, quick response (QR) code, and a link to the online survey among their social network. The distribution of the yer occurred through WeChat Moments ("Peng You Quan" in Chinese) or their WeChat groups ("Wei Xin Qun" in Chinese). Interested individuals who clicked on the link were directed to an eligibility screener. Each eligible participant voluntarily completed an online consent form by acknowledging that they understood the purpose, risks, and bene ts of the study prior to completing the survey. On average, participants took 12 minutes to complete the anonymous online survey. The questionnaire was available in both English and Chinese languages and was translated and backtranslated to ensure culture meaning. 13

Study measures
Sociodemographic characteristics included age, sex, educational level, income, health, employment, and marital status. Income was strati ed based on the relationship to the national levels.
Traveling history in the past 30 days included whether they had traveled after the COVID-19 outbreak, and whether they were put in quarantine. Living environment was based on with whom they lived, and the region where they lived, strati ed by the density of COVID-19 cases, with Hubei province being the highest. We also measured where participants accessed information pertaining to COVID-19 and what measures that their communities had taken to control COVID-19.
Participants' self-perceived health status were measured by the question "How is your current health status?" with a response of "Very good", "Good", "Fair", "Poor", and "Very poor". These answers were dichotomized into "Good" ("Very good" + "Good"), and "Not good" ("Fair" + "Poor" + "Very poor"). In addition, we assessed the frequency of the following health-related behaviors, before and after the COVID-19 outbreak, which included wearing face masks, practicing physical distancing, washing hands, spitting, and showering. The questions related to each construct are included in Table 2.
The primary outcome was the presence of anxiety symptoms severity, which was measured by the Generalized Anxiety Disorder 7-item (GAD-7) scale, which has good reliability, sensitivity, and speci city for measuring anxiety in Chinese populations. 14 Generalized anxiety disorder (GAD) cut-offs for mild, moderate, and severe symptoms including scores of 5-9, 10-14, and >15, respectively. Other screening for mental illness included assessment of obsessive-compulsive symptoms using the Obsessive-Compulsive Inventory 15 and depression using the Patient Health Questionnaire-2. 16

Statistical analyses
All data analyses were performed using SAS 9.4 (SAS Institute, Cary, North Carolina, United States). Data were presented using frequencies and means. Chi-square test was used to compare the behaviors of wearing face masks and practicing physical distancing before and after the COVID-19. Student's t-test was used to examine differences in hand washing, spitting, going outside, and showering, before and after the outbreak. Logistic regression was used to examine the association between potential explanatory variables and the presence of anxiety. Anxiety was dichotomized for values >4, which is associated with the presence of anxiety symptoms. Any variable signi cant at p<0.10 in bivariate analyses were then entered into the multivariate logistic regression model to determine the odds ratio and 95% con dence intervals for the nal model. An additional analysis (Supplementary Data) for moderate to severe anxiety symptoms (cut-off >9) was also conducted.

Participant characteristics
Most participants (Table 1) were female (68.9%), in their 30s (31.3±11.9), completed a college degree (89.5%), and perceived themselves to be in good health status (74.8%). Nearly 34% of the participants have an annual income of greater than ¥ 60,000 (12 times greater than the international poverty threshold; equivalent to 8,571 USD), and 16.0% of the participants were healthcare providers. Nearly all (93.1%) participants were living with families and remained in one city during the 30 days prior to the study. Participants were from regions with different density of COVID-19 cases, 22.8% of them were from the epicenter -Hubei province. Nearly half of the participants were married (47.4%). Most participants reported that they didn't travel (95.5%) after the COVID-19 outbreak, and most communities (93.4%) had taken strict measures to control COVID-19. Overall, the top three commonly used preventative measures in Chinese urban areas were: controlling the entry and exit of people by checking their body temperature, banning gatherings in the community, and cleaning and sanitizing communal spaces ( Figure 2). The number of participants who wore face masks and practiced physical distancing, and the frequency of hand washing increased signi cantly after the COVID-19 outbreak (p<0.001). The rate of spitting in public places and going outside of one's home decreased signi cantly (p<0.001; Table 2).

[INSERT TABLE 3 HERE]
3.4 Correlates of moderate to severe generalized anxiety disorder As shown in Table 4 in the supplementary appendix, poor self-perceived health status (aOR=1.73, p<0.01), higher frequency of washing hands (aOR=1.02, p=0.03), living in Hubei (aOR=2.85, p<0.01), and meeting screening criteria for depression (aOR=24.20, p<0.01) were independently associated with moderate and severe anxiety symptoms.

Discussion
The unprecedented COVID-19 pandemic has raised signi cant public health concerns and has an extended impact on the psychological well-being of society, especially in urban areas most profoundly impacted by the disease. The COVID-19 epidemic unleashed a rapid and cataclysmic response by society, in which we report the profound protective response to the COVID-19 outbreak. In response to government guidance and clear messaging, frequency of hand washing and physical distancing practices increased, while venturing outside in crowded urban spaces or spitting in public places decreased. Though public spitting is unlawful in some Chinese cities like Beijing, 17 Hangzhou, 18 and Tianjin, 19 it remains legal and practiced elsewhere; but during COVID-19, such practices markedly reduced. On May 15, 2020, the Chinese Government of Shanxi province passed China's rst provincial law prohibiting spitting in public places, which aimed to change uncivilized behaviors and prevent the spread of infectious diseases. 20,21 Unlike physical distancing and handwashing that were widely recommended by public health authorities' sources, public spitting messages were mostly from non-o cial online sources. Another explanation for a decrease in this behavior is that people remained inside more and such public spitting opportunities were less. These ndings do not appear to be driven by social desirability response since other hygienic measures that were not suggested in governmental and public sources, like showering, were not impacted.
Anxiety levels were high in this large sample. Surveys from multiple countries, including China, 22 Germany, 23 Italy, 24 Saudi Arabia, 25 and Turkey 26 have shown that the prevalence of anxiety increased signi cantly with the global escalation of the COVID-19 pandemic. For example, prior to the COVID-19 outbreak, the prevalence of anxiety among a national sample of 38,294 Chinese urban dwellers was 5.3%, 27 and in a post-COVID survey of 7,236 Chinese citizens, 22 the prevalence rose to 35.1% using the same GAD screening instrument. Our study had a similar prevalence to the other, but we identi ed more factors that were correlated with GAD. Unlike the other survey that found younger age (<35 years) and time spent (>3 hours daily) focusing on COVID-19, our assessment of urban dwellers found that GAD was correlated with being a healthcare worker, living in region more profoundly impacted by COVID-19, having poorer self-perceived health status, having a college education and having moderate to severe depression.
Findings from our urban study, combined with those from both urban and non-urban dwellers, underscores the importance of providing support to a large number of people impacted by a new and evolving epidemic. Our ndings, however, provide important insights into how to focus such intervention efforts to provide trauma-informed care. For example, healthcare workers, which have been identi ed elsewhere to experience exceptional levels of stress, should be targeted for screening and intervention. Additionally, those with lower self-perceived health should be targeted. Many such individuals may potentially have co-morbid conditions that increase their likelihood of experiencing more severe COVID-19 disease if they become infected. 28,29 This is especially true since they may perceive they are unable to access needed healthcare services since during the pandemic, only essential medical visits were allowed, leaving them without support to self-manage their medical conditions. While patients with depression may also experience anxiety symptoms, in our survey, these variables were not collinear, but suggests that such patients have a lower psychological reserve to deal with stress and experienced heightened anxiety symptoms. This nding is born out in our additional analysis that shows depression is highly correlated with moderate to severe anxiety symptoms.
In the initial stage of responding to COVID-19, most healthcare facilities in the outbreak regions shuttered their doors to patients, except for those with urgent needs. Consequently, care was transitioned to telehealth. One potential implication from this survey is that healthcare providers, when providing tele-health to patients with chronic diseases that may heighten risk for more severe consequences of COVID-19, and even those with depression, should screen such patients for GAD and provide supportive counseling, which can effectively be done using tele-health. 30 As pandemics evolve, unscienti c ideas may proliferate about how infections can be prevented, treated and cured. In the early stage of COVID-19, rumors of several effective treatments were touted to suppress COVID-19 from unsubstantiated online sources, which in turn generated the public anxiety because everyone wanted the treatments, yet they were unavailable for purchase. 31 Providing accurate health information guided by science is therefore important to mitigate excess anxiety during the pandemic. Unsubstantiated rumors have been found to provoke anxiety and exacerbate mental health before SARS, avian u, and swine u epidemics. 32-34 In times of crisis, it is even more important to ensure information is accurate and scienti cally grounded to ensure that people feel safe. In the case of COVID-19, considerable uncertainty existed and in an evolving crisis, conspiracy theories and hyperbole abound which, in turn, perpetuates anxiety. 35 Health information, however, often comes from multiple sources, but should be derived from someone who is respected, has authority and trusted by society.
During an infectious pandemic that requires physical distancing, mobile technology may be crucial as a conduit of accurate (and sometimes inaccurate) information. 36, 37 Such information is more powerful, however, when collaborative learning is used and people can teach each other as long as an expert is there to guide discussion. 38 Collaborative learning in communities, de ned as integrating meaningful community engagement with education, instruction, and re ection to promote the capacity of individuals to take collective actions to improve the quality of life, is a key method considered by many international and national bodies to prepare for, respond to, and recover from emergency situations. 39, 40 Mobile technology-based interventions (e.g., telemedicine) could easily be repurposed to promote community learning not only as a dissemination method of accurate information, but also to address anxiety, maintain social connectivity while physically distancing, mobilize resources, and support communitybased networks of people in need. 41 For instance, a tele-health visit using video or telephone from local clinicians could screen, motivate and treat patients and families. Even when stigma about mental illness is common, as it is in China, 27 brief motivational enhancement techniques can be deployed as part of trauma-informed care that can be done routinely without making a diagnosis. Building such interventions and messages in public forums and giving people an opportunity to discuss how the pandemic is affecting them can provide an open opportunity for assistance. This would be especially crucial in some regions of mainland China where it might be considered "abnormal" or a shameful to seek treatment for anxiety. Such individual or public messaging to provide trauma-informed care to individuals with anxiety would minimally include examples to support self-regulation of stressors, prioritize healthy relationships, explain why health restrictions are being made that otherwise limit routine daily activities, visualize what to expect within reason of what is known, and reframe behaviors to account for people not being at their best during times of crisis. 42 It is no surprise that urban dwellers living closest to the epicenter and with the high density of COVID-19 cases (e.g., Hubei) experienced the most anxiety, relative to those in less dense COVID-19 cases. These individuals had the most uncertainty as they were impacted rst and had the least amount of accurate information. Such individuals might have also perceived themselves at highest risk, which is similar to our nding that healthcare workers, also at substantial risk, experienced heightened anxiety symptoms.
Of note, healthcare workers had an increased association of experiencing mild anxiety symptoms, but not moderate or severe anxiety symptoms. One might expect that such individuals would have the most severe anxiety symptoms because they are at the highest risk for COVID-19 combined with extreme workloads during a heightened crisis management scenario where personal protective equipment and testing were inadequate. 43 One potential explanation is that healthcare workers self-manage life and death situations on a daily basis and have established functional coping mechanisms. Alternatively, data from Wuhan suggested that over half of healthcare workers accessed support services, which may have helped them better deal with anxiety-provoking stressors. 44 Last, the healthcare workers in this survey may not have been those providing the most direct patient care and therefore did not experience the highest levels of anxiety.
Though this large survey assessing responses and anxiety symptoms across a large number of regions of China had many important and new ndings, it is without limitations. First, convenience sampling using WeChat does not make this a fully representative sample and restrict generalizability. Second, though markedly higher levels of generalized anxiety disorders were reported relative to the general population before COVID-19, we could not infer that COVID-19 was causative due to the cross-sectional nature of the survey. Last, some factors that may have contributed to anxiety symptoms may not have been measured, like time spent online seeking COVID-related information or various types of coping mechanism. Future research should more comprehensively study the possible negative psychological consequences of various countermeasures to nd out the best solution. Finally, this study compared anxiety levels from before the outbreak to March 2020 but did not assess changes in anxiety levels over the entire period of the pandemic. More research should be conducted to examine changes in mental health outcomes over the entire pandemic period.

Conclusion
COVID-19 has had a profound impact on China initially and continues to do so globally. In China, urban residents markedly changed their health behaviors in response to the evolving epidemic. These urban dwellers also experienced profound levels of anxiety, especially in settings closest most profoundly impacted by the epidemic and in those most vulnerable like healthcare workers and those with poor perceived health, including those with depression. Much has been learned from prior epidemics to guide a trauma-informed response, but when physical distancing practices are imposed, innovations in reaching screening, motivating and treating such individuals at increased risk for anxiety are urgently needed. Technology-based interventions like online collaborative learning environments and tele-health can be used to solve such obstacles to service delivery. Such lessons can be useful as new settings become susceptible to COVID-19 and as secondary outbreaks emerge before an effective vaccine is made widely available.   * In bivariate logistic regression models, those variables whose P-value is less than 0.1 was included in the multiple logistic regression.
** Variables that have been significant at 0.05 level in multiple logistic regression model. ‡ Participants who divorced or lost spouse were categorized into the categorize of Married.
A Health-related behavior after the COVID-19 outbreak.
B Health-related behavior before the COVID-19 outbreak.

Declarations
Compliance with Ethical Standards

Source of Funding
This work was supported by grants from the National Institute on Drug Abuse for career development (K01DA051346 to RS and K24 DA017072 to FLA).

Con icts of Interest
The authors have no con icts of interest to disclose.

Ethical approval
The study protocol was approved by the Institutional Review Board of Yale University and received ethical approval from Wuhan University. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent
Electronic informed consent was obtained from all individual participants included in the study. Figure 1 In this study, we used a modi ed snowball recruitment strategy where 11 participants (seeds) were recruited one each from 11 representative provinces in China. Eleven representative provinces were Qinghai, Ningxia, Xinjiang);9 and 2) COVID-19 severity as was categorized by China National Health Commission10 (diagnosed COVID-19 cases≥10,000; 1,000-9,999; 100-999; ≤99) based on the percentage of provinces in each stratum in March 2020 Note: The designations employed and the presentation of the material on this map do not imply the expression of any opinion whatsoever on the part of Research Square concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. This map has been provided by the authors.